Atraumatic arthroscopic instrument sheath

ABSTRACT

An arthroscopic inflow and outflow sheath providing an improved inflow and outflow system reducing the diameter of a continuous flow system while eliminating the need for a third portal during arthroscopy. The improved arthroscopic inflow and outflow sheath comprises an elongated atraumatic sheath having an inner surface, outer surface, proximal end, and distal end. The atraumatic sheath further comprises plurality of ribs or webs extending from the inner surface of the sheath and designed to contact an outer surface of the arthroscope creating outer lumens facilitating the inflow and outflow of fluid to a surgical site.

This application is a continuation-in-part of U.S. application Ser. No.10/769,629 filed Jan. 29, 2004.

FIELD OF THE INVENTIONS

The inventions described below relate the field of arthroscopic surgicalinstruments.

BACKGROUND OF THE INVENTIONS

Medical science has long sought ways to minimize the dangers and traumainherent in invasive surgical procedures. To this end, surgicaltechniques and instruments have been developed which, among otherthings, reduce the size and number of the incisions required to performvarious surgical procedures. These techniques and instruments have beenremarkably successful. Procedures that only a few years ago wouldrequire multiple incisions several inches in length, are today beingperformed with just a few one-ince incisions.

During minimally evasive surgeries, surgical instruments such astrocars, cannulas, and optical medical devices, including endoscopes,cystoscopes, arthroscopes, laparoscopes, etc., are inserted throughsmall incisions or portals in a patient's body or body cavity andmanipulated to perform surgical procedures within the patient.

Minimally invasive surgical procedures are safer than open surgery andresult in quicker patient recovery, shorter hospital stays, and lowerhealth care costs. Accordingly, minimizing invasiveness continues to beof importance, and there is a continuing need for devices and methodsthat achieve this objective.

One significant barrier to further minimizing the invasiveness ofsurgery is the necessity of many surgical instruments to have fluidchannels. These channels effectively add to the outer diameter of theinstruments. For example, known endoscopic instruments provideinflow/outflow through an assembly of concentric sheaths that definechannels for inflow and outflow of fluids to and from the operative orsurgical site. The fluid may be an irrigating solution that helpsmaintain a clear view of the site for the physician. Certain knownirrigating systems provide simultaneous and continuous inflow andoutflow. These systems are known as “continuous flow” systems.

The known inflow and outflow endoscope systems introduce an irrigatingfluid into the surgical site. For this purpose, the endoscope has aninflow channel defined by the inner surface of the inner sheath. Thefluid passes through the channel and exits the distal end of the sheathto irrigate the operative site. Fluid at the surgical site may bewithdrawn through an outflow channel defined by the outer surface of theinner sheath and the inner surface of a surrounding outer sheath. Theoutflow channel originates at the distal end (front end) of theinstrument and transports fluid to an exit point at the proximal end ofthe outer sheath. The diameter of these systems require larger surgicalportals.

Another barrier to minimally invasive surgery is the number of incisionsor portals required by the surgeon in order to perform a surgicalprocedure. During many procedures, multiple portals are required toprovide irrigation of the surgical site and removal of debris, view thesurgical site with use of an endoscope, and facilitate the use ofspecialized surgical equipment to repair the injury or abnormality. Eachincision creates additional risk of infection and extends recovery time.

A procedure where less invasive surgical techniques may be beneficial isarthroscopic surgery. Presently, arthroscopic surgical techniques use astandard three-portal (incision) technique. A first portal is made inthe patient and then used to insert an arthroscope to view the surgicalsite. A second portal is created to insert a specialized surgicalinstrument to correct the injury or abnormality. Also, a third portal isusually made and then used to insert an inflow cannula to distend thejoint. The inflow cannula is used to fill the joint with a sterile fluidto expand the joint and make room for the surgeon to see and work. Afterthe procedure, the joint is washed out with a stream of fluid, theinstruments are removed, and the portals are closed with stitches,staples, or Steri-strips. Having multiple portals, coupled with largersized portals due to the size of the medical instruments, can be asource of postoperative pain and may inhibit postoperative recovery.

In arthroscopic surgery, as well as other surgical procedures, thereremains a significant need for improved techniques that reduce thenumber of portals used by surgeons as well as reduce the size of theportals while providing continuous fluid inflow and outflow. TheApplicant's improved inflow/outflow sheath reduces the diameter of thecontinuous flow system while eliminating the need for a third portalduring arthroscopic surgery.

SUMMARY

The devices and methods shown below provide for smaller and fewersurgical portals during arthroscopic surgery while also providingsubstantially simultaneous inflow and outflow of fluid to the surgicalsite. The distal end of the atraumatic sheath extends slightly past thedistal end of the rigid cannula, thereby providing a soft, blunt cushionover the distal end of the rigid cannula. The atraumatic sheath therebyprotects any surrounding tissue or objects from accidental injury ordamage while the arthroscope is manipulated inside the operating field.

The atraumatic sheath may also be provided as an inflow/outflow sheaththat allows a surgeon to drain fluids from or introduce fluids into thesurgical field, thereby keeping the surgical field clear. Theinflow/outflow sheath is a multi-lumen tube into which the arthroscopeis inserted. The proximal portion of the sheath is provided with fluidports, a manifold and other means of controlling the flow of fluidinside the sheath. The distal portion of the inflow/outflow sheath isprovided with a plurality of holes. Each hole communicates with one ormore of the lumens inside the tube, thereby allowing fluid to flowbetween the surgical field and sources or sinks located outside thepatient. The inflow/outflow sheath thereby allows the surgeon tomaintain a clear surgical field and protect the patient from accidentalinjury while eliminating the need for a third irrigation instrument.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows a method of performing arthroscopic surgery on a patient.

FIG. 2 shows an atraumatic sheath for use with arthroscopic instruments.

FIG. 3 shows an atraumatic sheath for use with arthroscopic instrumentsand an arthroscope disposed inside the atraumatic sheath.

FIG. 4 shows an atraumatic sheath for use with arthroscopic instruments,an arthroscope disposed inside the atraumatic sheath and an irrigationtube disposed on the sheath.

FIG. 5 shows a cross section of the atraumatic sheath shown in FIG. 2and an arthroscopic instrument disposed inside the atraumatic sheath.

FIG. 6 shows an inflow/outflow atraumatic sheath for use witharthroscopic instruments.

FIG. 7 shows an inflow/outflow atraumatic sheath for use witharthroscopic instruments and an arthroscope disposed inside theatraumatic sheath.

FIG. 8 shows a cross section of the distal portion of the inflow/outflowatraumatic sheath of FIG. 7.

FIG. 9 shows a cross section of the distal portion of an inflow/outflowatraumatic sheath.

FIG. 10 shows a cross section of the distal portion of an inflow/outflowatraumatic sheath.

FIG. 11 shows a cross section of the distal portion of an inflow/outflowatraumatic sheath.

FIG. 12 shows a cross section of the distal portion of an inflow/outflowatraumatic sheath.

FIG. 13 shows a cross section of the distal portion of an inflow/outflowatraumatic sheath.

FIG. 14 shows a cross section of the distal portion of an inflow/outflowatraumatic sheath.

FIG. 15 shows a cross section of the distal portion of an inflow/outflowatraumatic sheath.

FIG. 16 shows a cross section of the distal portion of an inflow/outflowatraumatic sheath.

FIG. 17 shows an inflow/outflow atraumatic sheath for use witharthroscopic instruments.

FIG. 18 shows a cross section of the distal portion of theinflow/outflow sheath shown in FIG. 17.

FIG. 19 shows an inflow/outflow sheath having a distal portion that hasan inner diameter that closely conforms to the outer diameter of thedistal portion of an arthroscope.

FIG. 20 shows a continuous inflow/outflow atraumatic sheath with atissue retention feature in the shape of radially extending ridges.

FIG. 21 shows a continuous inflow/outflow atraumatic sheath with atissue retention feature in the shape of a threaded screw.

FIG. 22 shows a tissue retention module disposed over an atraumaticsheath.

FIG. 23 shows a tissue retention module.

DETAILED DESCRIPTION OF THE INVENTIONS

FIG. 1 shows a method of performing arthroscopic surgery on a patient byusing an arthroscopic instrument 2 sheathed in an atraumatic introducersheath 3. An arthroscopic instrument may be an arthroscope, endoscope,awl, pick, shaver, etc. In FIG. 1, the arthroscopic instrument 2 shownis an arthroscope. (The various parts of the arthroscope are shown inphantom to indicate their positions inside the sheath.) Variousanatomical landmarks in the patient's knee 4 are shown for reference,including the femur 5, patella 6, posterior cruciate ligament 7,anterior cruciate ligament 8, meniscus 9, tibia 10 and fibula 11. Duringsurgery, the surgeon introduces the arthroscope 2 into the knee via afirst incision 12 in order to visualize the surgical field. A trimminginstrument 13 is introduced through a second incision 14 to remove ortrim tissue that the surgeon determines should be removed or trimmed.Optionally, an irrigating instrument 15 may be introduced through athird incision 16 in order to irrigate the surgical field and therebymaintain a clear view. As provided below, the irrigating instrument maybe replaced by a combined arthroscope and inflow/outflow atraumaticsheath.

The arthroscope 2 is an optical instrument 17 surrounded by a rigidcannula 18 having a distal edge that typically is cut at an angle. Toprotect the patient from unintended injury or trauma during theprocedure, the arthroscope has been inserted into a resilient, outerintroducer sheath or atraumatic sheath 3 that extends over the rigidcannula. The distal tip 19 of the atraumatic sheath extends distallyjust past the distal end of the arthroscope and rigid cannula to furtherprotect the patient.

FIGS. 2 through 4 illustrate the atraumatic sheath 3. The atraumaticsheath is a tube of a resilient material, such as a soft plastic orrubber. The inner diameter of the atraumatic sheath is sized anddimensioned to closely fit over the outer diameter of an arthroscopicinstrument. The distal tip 19 of the atraumatic sheath is provided witha shape that closely approximates the shape of the distal tip of thearthroscope and/or the rigid cannula. A flange 30 disposed around thedistal end of the sheath prevents the distal tip of the rigid cannulafrom gouging the patient. The flange is integral with the walls of thesheath and extends inwardly towards the axis of the sheath. The flangeis sized and dimensioned to prevent the distal tip of the rigid cannulafrom accidentally slipping distally during a surgical procedure. Anopening 36 is provided in some atraumatic sheaths so that the surgeonmay insert the endoscope or other instruments through the opening andinto the surgical space. The distal lens 31 of an optical instrument isshown for reference in FIGS. 3 and 4.

The proximal end 32 of the atraumatic sheath is provided with a tab 33to allow medical personnel to easily pull the atraumatic sheath over therigid cannula, arthroscope and/or arthroscopic instrument. The proximalend of the atraumatic sheath may also be provided with fittings, such asa locking hub or snap latches, that attach to fittings or openingsdisposed on the arthroscope or other instrument, thereby securing theatraumatic sheath.

The outer surface of the atraumatic sheath may be provided with a smoothcoating to allow the arthroscope and rigid cannula to more easily movewithin an operating site. For example, the sheath may be provided with aTeflon® (PTFE or expanded polytetrafluoroethylene) coating or coveredwith a water-activated lubricant. In contrast, the inner surface of theatraumatic sheath (the walls that define the lumen of the tube) may beprovided with a non-slip coating or other high coefficient of frictioncoating. For example, the inner surface of the atraumatic sheath may becoated with a co-extruded tacky thermoplastic elastomer (TPE). Thenon-slip coating prevents the sheath from easily slipping over the outersurface of the rigid cannula or arthroscope, thereby helping to preventthe atraumatic sheath from twisting or slipping around the arthroscope.

FIGS. 3 and 4 show an atraumatic sheath 3 for use with arthroscopicinstruments and an endoscope or arthroscope 2 disposed inside theatraumatic sheath. The atraumatic sheath shown in FIG. 3 is providedwith a balloon 34 on the distal portion of the sheath. (The balloon maybe integrally formed with the sheath.) The balloon allows a surgeon toopen a space within tissue, thereby dissecting the surgical field. Thearthroscope may then be extended distally out of the opening 36 and thesurgical space visualized. In addition, the distal end of the sheath maybe provided with a distally projecting spoon or other distallyprojecting object to prop open a space in front of the arthroscope. Theballoon and the distally projecting spoon thus provide a means fordissecting or retracting tissue to form a small surgical space.

FIG. 4 shows an atraumatic sheath 3 having a second, working tube 35.The working tube allows irrigation, fiber optics, sutures, needles,probes or surgical tools through the lumen. The atraumatic sheath shownin FIG. 4 may be combined with the atraumatic sheath shown in FIG. 3 toprovide an atraumatic sheath with both a balloon and a working tube.

FIG. 5 shows a cross section of the atraumatic sheath 3 shown in FIG. 2and an arthroscopic instrument 2 disposed inside the sheath. Theatraumatic sheath is provided with a tab 33 on the proximal end of thesheath in order to increase the ease of pulling the sheath over thearthroscope. The distal end of the sheath is provided with an opening 36to allow light to pass between the arthroscope and the operating spaceand, optionally, to allow additional instruments to pass through oralongside the arthroscope and into the surgical field. The walls 37 ofthe sheath at the distal end 19 of the sheath are thicker than the restof the sheath walls to form a flange 30 at the distal end of the sheath.(The flange may be a separate ring of material attached to the inside ofthe sheath.) The flange covers the sharp distal tip of the arthroscopicinstrument and prevents the instrument from slipping distally throughopening 36. The rest of the walls of the atraumatic sheath are thin inorder to minimize the overall thickness of the combined sheath andarthroscopic instrument.

In use, the atraumatic sheath is provided and pulled over anarthroscopic instrument. (The instrument may also be thought of as beinginserted into the sheath.) The sheathed arthroscopic instrument is theninserted into the surgical site and the surgeon performs a medicalprocedure therein. If a balloon is provided, the balloon is used todissect tissue so that the arthroscope may be extended distally out ofthe opening 36 and the surgical space visualized.

FIGS. 6 and 7 show an inflow/outflow atraumatic sheath 50 and anarthroscope 2 disposed inside the sheath. Like the sheath shown in FIG.2, the inflow/outflow atraumatic sheath 50 is formed of a resilientmaterial that protects the patient from accidental injury should thearthroscope poke at or scrape along tissue. The sheath material may alsobe radiopaque. A preferred durometer hardness of the sheath material isin the range of about 40 Shore A to about 90 Shore D. In this hardnessrange the sheath is sufficiently resilient that the sheath protects thepatient from accidental injury but is sufficiently hard to prevent thelumens within sheath from collapsing.

The inflow/outflow sheath 50 is a multi-lumen tube into which anarthroscope is inserted. Each lumen extends from the distal portion 51of the sheath to the proximal portion 52 of the sheath. The proximalportion of the sheath is provided with one or more fluid ports, such asfirst port 53 or second port 54; one or more stopcocks 55 or fluidswitches; one or more valves, such as an anti-backflow valve; a manifold56; or other means of controlling the flow of fluid inside the sheath.The distal portion 51 of the inflow/outflow sheath is provided with aplurality of holes 57. Each hole communicates with one or more of thelumens inside the tube, thereby allowing fluid to flow between thesurgical field and the lumens inside the sheath 50. The plurality ofholes 57 positioned at the distal end of the inflow/outflow sheath 50 isparticularly useful during surgery. In traditional sheaths, fluid inflowand outlow occur at a single open end. The use of a single openingsheath causes debris to be suctioned directly towards the lens of thearthroscope. This results in a “snow storm” effect in a surgeons fieldof view during surgery. The plurality of holes located 57 on the side ofthe inflow/outflow sheath 50 allow debris to be suctioned away thearthroscope tip and out of the surgeon's field of view.

Prior to surgery, medical personnel or the device manufacturer insertsthe arthroscope into the inflow/outflow atraumatic sheath and securesthe sheath to the arthroscope via a set-screw, snap-on attachment, otherreleasable attachments or other means 58 for securing the sheath to thearthroscope. During use, a surgeon may cause a fluid, preferably saline,to flow from a fluid source 59, through the arthroscope and into thesurgical field, as shown by inflow arrows 60. (The arthroscope isprovided with one or more lumens, ports or working tubes that allowfluid to flow through the arthroscope and into the surgical field.) Inturn, blood, other fluids and debris are drained from the surgical fieldthrough the holes 57, as shown by outflow arrows 61, and flow throughone or more lumens in the sheath. The inflow of clear saline and theoutflow of cloudy fluid and debris allow the surgeon to maintain a clearsurgical field using a single instrument. In turn, this capabilityeliminates the need to use an irrigating instrument. Thus, the surgeonmay have a clear field of view while using only a two-incisionarthroscopic procedure.

FIG. 7 also shows that fluids are drained through the inflow/outflowatraumatic sheath by using a vacuum source 70 or gravity drainoperatively attached to a fluid port, such as port 53, connected to thesheath manifold 56. Fluids are provided through the arthroscope 2 from afluid source 59 (by using a pump or gravity feed) operatively attachedto a fluid port, such as third port 72 or fourth port 73 connected tothe arthroscope. Depending on the capabilities of the arthroscope andthe surgeon's needs, the vacuum source and fluid source may be connectedto different combinations of ports provided with the inflow/outflowsheath or the arthroscope. For example, the vacuum source may beattached to port 73 and the fluid source may be attached to port 72 onthe inflow/outflow sheath. In this case, the surgeon may both introducefluids into and drain fluids from the surgical site using only theinflow/outflow sheath. Thus, even if the arthroscope is incapable ofintroducing fluids to or draining fluids from the surgical site, theinflow/outflow sheath allows the surgeon to eliminate the need for theirrigation instrument. In any case, a pressure sensor, and flow ratecontrol system and feedback control system may be provided toautomatically monitor and control the rate of fluid flow into and out ofthe surgical site.

FIG. 8 shows a cross section of the distal portion of the inflow/outflowsheath 3 shown in FIG. 6. The inflow/outflow sheath 50 has a centrallumen 80, bounded by inner wall 81, through which the arthroscope isinserted. The sheath has four outer lumens, including a first outerlumen 82, a second outer lumen 83, a third outer lumen 84 and a fourthouter lumen 85 bounded by the inner wall 81, the outer wall 86 and fourrelatively stiff ribs 87 that extend between the inner and outer wallsand that run along the length of the sheath. The distal end of thesheath in the area of the outer lumens 82, 83, 84 and 85 is sealedclosed and provided with a rounded shape to help prevent injury to thepatient (the central lumen remains open to accommodate the arthroscopicinstrument). Holes 57 or apertures disposed in the outer wall allowfluids to flow into or out of the outer lumens. For example, lumens 82and 84 could serve as passages through which fluids are introduced intothe surgical site and lumens 83 and 85 could serve as passages throughwhich fluids are drained from the surgical site. During another surgicalprocedure, all four lumens could be used to either drain or introducefluids. Thus, the surgeon has the option of using the inflow/outflowatraumatic sheath in many different modes. (In addition, the sheath maybe formed with more than or fewer than the four ribs shown, so long asat least one outer lumen remains open to fluid flow after the sheath andscope have been inserted into the surgical site.)

FIGS. 9 through 16 show cross sections of the distal portion of variousinflow/outflow atraumatic sheaths. FIG. 9 shows an inflow/outflow sheathhaving a second set of inner lumens, including a first inner lumen 100,a second inner lumen 101, a third inner lumen 102 and a fourth innerlumen 103. With this design, the surgeon can increase the rate of fluidexchange by using all of the inner lumens to introduce fluids into thesurgical site and by using all of the outer lumens 82, 83, 84 and 85 todrain fluid from the surgical site (or visa versa).

FIG. 10 shows an inflow/outflow sheath 50 without an inner wall 81.Instead, the outer surface 88 of the arthroscope 2 serves as the innerwall of the sheath 50 once the arthroscope has been inserted into thesheath 2. The four, relatively stiff ribs 87 form a seal with the outersurface 88 of the arthroscope, thereby creating the four outer lumens82, 83, 84 and 85. The ends 104 of the ribs may be provided with elasticflanges or extensions to enhance the seal made between the ribs 87 andthe arthroscope 2. This configuration reduces the overall size of thecombined inflow/outflow sheath and arthroscope. (If the outer wall 86 ismade of an elastomeric material, then the tube can stretch radially toaccommodate a variety of sizes of arthroscopes.).

As depicted in FIG. 10, the arthroscope 2 is inserted into the sheath 50through the central lumen 80. The arthroscope 2 may or may not becovered by a secondary protective sheath prior to insertion. Onceinserted, the outer surface 88 of the arthroscope 2 comes in contactwith the flanges or extensions of the ribs 87. The land of a rib mayalso be used to contact the outer surface of the arthroscope 2 when theribs 87 do not have flanges or extensions. The force of the outersurface 88 of the arthroscope 2 pushing against the ribs 87 and the ribflanges or rib extensions forms a seal between the ribs 87 and the outersurface 88 of the arthroscope 2. Outer lumens 82, 83, 84 and 85 arecreated by the ribs, the outer surface of the endoscope 88, and innersurface 89 of the outer wall 86 of the inflow/outflow sheath. The ribsact as longitudinal struts that prevent the sheath from collapsing asthey support the sheath under compression. The ribs reduce theunsupported span of the thin outer wall in the traverse axis, furtherpreventing the collapse of the sheath. The seals formed by the contactbetween the ribs 87 and the outer surface 88 of the arthroscope preventfluids from flowing between the outer lumens 82, 83, 84 and 85. Theouter lumens 82, 83, 84 and 85 facilitate the continuous inflow andoutflow of fluids to and from a surgical site from outside the patient1. Check valves or gates may also be coupled to the inner wall of theinflow/outflow sheath 50 within the outer lumens 82, 83, 84 and 85 toprevent outflow fluids from flowing back towards the surgical site andto prevent inflow fluids from flowing out the proximal end of thesheath.

The inflow/outflow sheath 50 depicted in FIG. 10 typically has an outerdiameter measuring about 5 to 7 millimeters when the sheath ismanufactured for use with arthroscopic instruments in larger joints,though this size may vary depending on the diameter of the arthroscopicinstrument. When the inflow/outflow sheath is manufactured for use witharthroscopic instruments in smaller joints, the sheath 50 has an outerdiameter measuring about 2 to 3 millimeters. The outer wall thickness 86of the inflow/outflow sheath 50 is typically 1 millimeter or lessdepending on the extrusion and material comprising the tube. Theinflow/outflow sheath 50 can fit a range of arthroscopes +/−10% of thesheath's nominal diameter. The ribs 87 extend from the inner surface ofthe inflow/outflow sheath inwardly and make a tight fit when thearthroscope is inserted.

A smaller outer diameter inflow/outflow sheath 50 is particularly usefulin arthroscopic surgery. Due to the unique, the inflow/outflow sheath 50has been able to achieve a 30% reduction in diameter when compared tomulti-lume cannula devices requiring an inner wall of a cannulacontacting the outer wall of the arthroscope. Presently, arthroscopicsurgical techniques use a standard three-incision technique. A firstincision is made and used to insert an inflow cannula to distend thejoint. The inflow cannula is used to fill the joint with a sterile fluidto expand the joint and make room for the surgeon to see and work. Asecond incision is made in the patient and used to insert an arthroscopeto view the surgical site. A third incision is created by the surgeon toinsert a specialized surgical instrument to correct the injury orabnormality. After the procedure, the joint is washed out with a streamof fluid, the instruments are removed, and the portals are closed withstitches, staples, or Steri-strips. Recently, surgeons have begun toshift to a two-incision technique during arthroscopic. Surgeons use oneincision for inserting the arthroscope and a second incision forinserting the specialized surgical instrument. This technique eliminatesa third portal by using an arthroscope with an inflow and outflowsheath. Sheaths currently used for inflow and outflow, however, do notfacilitate the continuous and simultaneous inflow and outflow of fluidsto and from a surgical site with a sheath having a reduced diameter.Present sheaths only facilitate alternating inflow and outflow of fluidsto the surgical site and these sheaths are of a larger diameterrequiring the incision to be larger. When in use, the Applicant'sinflow/outflow sheath 50 can facilitate the substanially simultaneousflow of fluids to and from a surgical site through the outer lumens 82,83, 84 and 85 while requiring a smaller size incision. Substaniallysimultaneous inflow and outflow allows the surgeon to keep the surgicalsite clean and the field of view clear.

A unique feature of the Applicant's inflow/outflow sheath 50 is theallowance of outflow to exceed inflow in the sheath 50. Higher outflowcapacity facilitates the removal of debris and bodily fluids from thesurgical site. Fluid pressure supplied to the inflow/outlow sheath 50 isusually standard arthroscopic distension pressure at a pressure head ofapproximately 6 feet to 8 feet of water, but this may vary depending onthe surgical application. Suction for use with the inflow/outflow sheath50 ranges from approximately 0 to 250 mm/Hg depending on the sheath sizeand surgical application. When the inflow/outflow sheath is used inconjunction with a 5.7 mm arthroscope, the inflow of fluid to a surgicalsite can be performed at the rate of 800 ml/min at 6 feet of water whileoutflow from the surgical site can be accomplished at the rate of 850ml/min at 21 mm/Hg suction. The higher outflow capacity is able toremove both the irrigation fluid and the additional debris and bodilyfluid coming from the patient during surgery.

FIG. 11 shows an inflow/outflow atraumatic sheath 50 similar to thatshown in FIG. 10. The relatively hard ribs 87 are pleated, but stillform a seal with the outer wall of the arthroscope 2, thereby formingthe lumens 82, 83, 84 and 85 once the arthroscope is inserted into thesheath. The sheath of FIG. 11 accommodates a variety of sizes ofarthroscopes because the pleated ribs will bend to a degree necessary toaccommodate larger sizes of arthroscopes, as shown in FIG. 12.

FIG. 13 shows an inflow/outflow atraumatic sheath 50 similar to thatshown in FIG. 11. The ribs 87 of this sheath are elastic tubes that forma seal with the outer wall of the arthroscope 2, thereby forming theouter lumens 82, 83, 84 and 85 once the arthroscope is inserted into thesheath. The sheath of FIG. 13 accommodates a variety of sizes ofarthroscopes since the tubes will compress to a degree necessary toaccommodate larger sizes of arthroscopes, as shown in FIG. 14.

FIG. 15 shows a “C”-shaped or slit inflow/outflow sheath 50. Like thesheath of FIG. 8, four outer lumens 82, 83, 84 and 85 are provided, withthe outer lumens bounded by three ribs 87, the inner wall 81 and theouter wall 86. When the arthroscope 2 is inserted into the sheath, asmall gap 105 may form between the respective tips of the first arcuatesegment 106 and the second arcuate segment 107. (As the arthroscope isinserted into the surgical space, tissue 108 will seal the gap andprevent fluids from leaking from the surgical space to outside thebody.) The sheath of FIG. 15 accommodates a variety of sizes ofarthroscopes since the arcuate segments will move radially outwardly asa larger arthroscope is inserted into the sheath, as shown in FIG. 16.

Optionally, a protrusion or a guide rail 109 may extend from either thearthroscope or the sheath. The guide rail helps the user align thesheath on the arthroscope while inserting the arthroscope into thesheath. The guide rail also prevents unwanted rotation or twisting ofthe sheath over the arthroscope during a surgical procedure.

FIGS. 17 and 18 show an inflow/outflow atraumatic sheath 50 and anarthroscope 2 inserted into the sheath. In contrast to theinflow/outflow sheaths shown in FIGS. 6 through 16, the outer wall 86 ofthe distal portion 51 of the sheath is made from a continuous tube (thedistal portion of the sheath is not provided with holes). Nevertheless,like the sheath of FIG. 8 the sheath of FIG. 17 has an inner lumen toaccommodate the arthroscope and four outer lumens to accommodate fluidinflow and outflow, including a first outer lumen 82, a second outerlumen 83, a third outer lumen 84, and a fourth outer lumen 85. The outerlumens are bounded by the inner wall 81, outer wall 86 and supportingribs 87. The instrument shown in FIG. 17 provides fluid inflow andoutflow out of the distal end 110 of the sheath.

FIG. 19 shows an inflow/outflow atraumatic sheath 50 having aclosely-conforming distal portion 111 that has an inner diameter thatclosely conforms to the outer diameter of the distal portion of anarthroscope 2. The fluid-conducting portion 112 of the sheath is setproximally from the closely conforming distal portion 111 of the sheath.The outer diameter of the fluid conducting portion 112 and the outerdiameter of the closely conforming distal portion 111 may be formedintegrally with each other such that both portions are part of the samesheath. Holes 57 disposed in the fluid-conducting portion 112 justproximally of the distal portion 111 of the sheath communicate with oneor more lumens inside the sheath, thereby allowing a surgeon to eitherintroduce or drain fluids from a surgical site. The sheath shown in FIG.19 has a distal portion 111 with a relatively small radius, since thesheath closely conforms to the arthroscope at the distal portion of thearthroscope. This provides the surgeon with the capability of insertingthe arthroscope into narrow surgical sites. In addition, thefluid-conduction portion still allows a surgeon to irrigate the surgicalfield with the combined sheath/arthroscope instrument.

FIGS. 20 and 21 shows a continuous inflow/outflow atramatic sheath 50with a tissue retention feature 113. The outer surface of the proximalportion 52 of the sheath is corrugated or provided with ridges 114 thatengage the tissue surrounding the surgical site and help prevent thesheath or instrument from being unintentionally forced out of theoperating field. The ridges 114 of the tissue retention feature 113 arecircumferentially disposed around the sheath and may be in the shape ofstraight ridges extending radially outward as illustrated in FIG. 20.The ridges 114 of the tissue retention feature 113 may also be in theshape of a threaded screw as illustrated in FIG. 21.

FIGS. 22 and 23 illustrate how the tissue retention feature isincorporated into a separate tissue retention sleeve 115 for use over anatraumatic sheath 50 not having tissue retention feature 113. In thisembodiment, the tissue retention sleeve has an inner diameter so sizedand dimensioned to fit over an atraumatic sheath. The tissue retentionsleeve is manufactured from an elastomer having a coefficient offriction that prevents the module from moving easily once the module hasbeen forcibly slid into position over the outer surface of theatraumatic sheath. The sleeve friction fits over the surgical instrumentor atraumatic sheath. The outer surface of the tissue retention sleeveis corrugated or is provided with ridges to help prevent the sheath orinstrument from being unintentionally forced out of the operating fieldwhen the sheath or instrument is provided with the tissue retentionsleeve. The ridges 114 on the sleeve are circumferentially around theouter surface of the module 114 and may be in the shape of straightridges extending radially outward. The ridges 114 may also be in theshape of a threaded screw.

The atraumatic sheath configurations may be designed or sized anddimensioned to conform to differently shaped instruments, the sheath isalso useful with other medical instruments and other surgical proceduresin which it is desirable to protect surrounding tissue from accidentaltrauma. For example, the atraumatic sheath may be disposed over atrimming instrument for use during arthroscopic surgery or over anenergy-delivering medical instrument, such as a laser or RF energyinstrument. Other procedures in which the atraumatic sheath is usefulinclude laparoscopic surgery and other kinds of endoscopic surgery. Inaddition, the various sheath configurations shown herein may be combinedto form additional types of instrument sheaths. Thus, while thepreferred embodiments of the devices and methods have been described inreference to the environment in which they were developed, they aremerely illustrative of the principles of the inventions. Otherembodiments and configurations may be devised without departing from thespirit of the inventions and the scope of the appended claims.

1. A system for performing arthroscopic surgery, said system comprising:an arthroscopic instrument suitable for performing an arthroscopicsurgical procedure; and an atraumatic sheath having an inner diametersized and dimensioned to permit fluid flow between the inner surface ofthe sheath and an outer surface of the arthroscopic instrument disposedwithin the sheath, said sheath further having a plurality of ribsextending inwardly from an inner surface of said sheath and runninglongitudinally along said sheath; wherein said ribs define lumensbetween the outer surface of the arthroscopic instrument and the innersurface of the sheath; wherein the atraumatic sheath is adapted to beremovably disposed over the arthroscopic instrument.
 2. The system ofclaim 1 wherein the sheath is characterized by an outer surface, whereinsaid outer surface is provided with a smooth coating.
 3. The system ofclaims 1 or 2 wherein the inner surface of the sheath is provided with anon-slip coating.
 4. The system of claim 1 further comprising a fluidsource in fluid communication with one or more outer lumens in thesheath.
 5. The system of claim 1 or claim 4 further comprising a vacuumsource.
 6. The system of claims 1, 4, or 5 further comprising a controlsystem controlling the inflow and outflow of fluid to the surgical site.7. The system of claim 1 further comprising check valves coupled to theinner surface of said sheath within the outer lumens.
 8. The system ofclaim 1 further comprising a first set of fittings disposed on theproximal end of the sheath and a second set of fittings disposed on thearthroscopic instrument, wherein the first and second sets of fittingsare adapted for releasable coupling, whereby the sheath is secured tothe arthroscopic instrument when the first and second sets of fittingsare secured together.
 9. The system of claim 1 wherein the atraumaticsheath is characterized by a distal portion, said distal portion havinga plurality of holes in fluid communication with one or more lumens andthe surgical site.
 10. The system of claim 1 wherein said ribs furthercomprise flanges.
 11. The system of claim 1 wherein said ribs furthercomprise extensions.
 12. The system of claim 1 wherein the outflow offluid equals or exceeds the inflow.
 13. An atraumatic sheath comprising:a tube characterized by a distal portion, a proximal portion, an outersurface, an inner surface, an inner diameter and an outer diameter;wherein the inner diameter of said tube is sized and dimensioned topermit fluid flow between the inner surface of the tube and an outersurface of an arthroscopic instrument when the arthroscopic instrumentis disposed within the tube; and a plurality of ribs extending inwardlyfrom the inner surface of the tube and running longitudinally along thetube; wherein said ribs further define lumens between the outer surfaceof the arthroscopic instrument and inner surface of the tube.
 14. Theatraumatic sheath of claim 13 wherein said ribs further compriseflanges, said flanges forming a seal between the ribs and the outersurface of an arthroscopic instrument when the arthroscopic instrumentis disposed within the sheath.
 15. The atraumatic sheath of claim 13wherein said ribs further comprise extensions, said extensions forming aseal between the ribs and the outer surface of an arthroscopicinstrument when the arthroscopic instrument is disposed within thesheath.
 16. The atraumatic sheath of claim 13 further comprising checkvalves coupled to the inner surface of the tube within the outer lumens,said anti-backflow gates operable to prevent the back flow of fluidwithin the lumens.
 17. The atraumatic sheath of claim 13 wherein saiddistal portion further comprises a plurality of holes in fluidcommunication with one or more outer lumens and a surgical site.
 18. Theatraumatic sheath of claim 13 further comprising a plurality ofcircumferential ridges, said ridges disposed on the outer surface of theproximal portion of the tube.
 19. A method of performing arthroscopicsurgery, said method comprising the steps of: providing a system forperforming arthroscopic surgery, said system comprising: an arthroscopicinstrument suitable for performing an arthroscopic surgical procedure;an atraumatic sheath having an inner diameter sized and dimensioned topermit fluid flow between the inner surface of the sheath and an outersurface of the arthroscopic instrument disposed within the sheath, saidsheath further having a plurality of ribs extending inwardly from aninner surface of said sheath and running longitudinally along saidsheath; wherein said ribs define outer lumens between an outer surfaceof the arthroscopic instrument and the inner surface of the sheath, saidlumens facilitating the inflow and outflow of fluid to and from asurgical site; wherein the atraumatic sheath is adapted to be removablydisposed over the arthroscopic instrument. placing the arthroscopicinstrument inside the sheath; and performing an arthroscopic surgicalprocedure with the system for performing arthroscopic surgery.
 20. Themethod of claim 19 further comprising the step of providingsubstantially simultaneous inflow and outflow of fluid to anarthroscopic surgical site.
 21. The method of claim 19 furthercomprising the step of providing substantially simultaneous inflow andoutflow of fluid to an arthroscopic surgical site wherein the outflow offluid is at a rate equal to or exceeding the inflow rate of fluid.
 22. Atissue retention device comprising: a sleeve having an outer surface anda bore extending therethrough, said bore having an inner diameter sosized and dimensioned as to frictionally fit over an outer diameter ofan arthroscopic surgical instrument; and a ridge disposed on the outersurface of the sleeve to prevent the surgical instrument from beingeasily removed from a surgical site.
 23. A tissue retention device ofclaim 22 wherein said ridge is helical and shaped as a thread.
 24. Atissue retention device of claim 22 wherein said ridge iscircumferential.
 25. A tissue retention device of claim 22 furthercomprising a plurality of circumferential ridges disposed on the outersurface of the sleeve.
 26. A tissue retention device of claim 22 whereinthe sleeve of the device comprises a sterilizeable elastomer.
 27. Adevice for use with an arthroscopic sheath comprising: a sleeve havingan outer surface and a bore extending therethrough, said bore having aninner diameter so sized and dimensioned as to frictionally fit over anouter diameter of an arthroscopic sheath; and a ridge disposed on theouter surface of the sleeve to prevent the surgical instrument frombeing easily removed from a surgical site.
 28. A tissue retention deviceof claim 27 wherein said ridge is helical and shaped as a thread.
 29. Atissue retention device of claim 27 wherein said ridge iscircumferential.
 30. A tissue retention device of claim 27 furthercomprising a plurality of circumferential ridges disposed on the outersurface of the sleeve.
 31. A tissue retention device of claim 27 whereinthe sleeve of the device comprises a sterilizeable elastomer.